Editorial — Future shock: Challenges facing U.S. radiology

“Future shock” is a phrase derived from the title of a book published in 1970 by Alvin Toffler.1
In its most succinct form, it refers to a mental state in which
individuals, groups or even whole societies experience “too much change
in too short a period of time.”2 This term often resonates
with me as I have spoken this year with radiologists around the USA and
others countries. For us in diagnostic imaging there has been a lot of
change in a very short time and not all of it has been good.

We are in a relative interregnum in the US health care reform
process. To paraphrase a quote from Winston Churchill, we are not at the
beginning of the end but we might be at the end of the beginning. This
is a good time for us to do a strategic assessment of the opportunities
and threats to the current practice of radiology — not just federal
health care reform, but the many other factors that are at work. Several
key strategic challenges are combining to create a chronic form of
future shock in those of us that are experiencing these rapid and at
times chaotic changes in United States radiology. Let’s review the
individual shocks or challenges individually to better understand how
these breaking trends impact our specialty.

Declining reimbursement

Perhaps no other topic in radiology is as capable of generating more
anger and virulent debate than the decline in per unit reimbursement for
work radiologists do. While most of us see this as a destructive and
fearsome trend, some radiologists see it as a deserved correction or
punishment for a specialty that has been historically overpaid. That’s
certainly a point of debate, but the facts are that there have been
multiple serious reductions in reimbursement beginning during the George
W. Bush presidential administration with the Multiple Procedure Payment
Reduction and Deficit Reduction Acts and then accelerating through the
Obama administration. This has occurred not only to the professional
component of what our service, but to the technical component as well.
The latter has occurred over ten times in recent years.3

According to a good friend who is in a prominent practice in a major
western city these effects have reduced the practice’s reimbursement on a
per case basis by almost 50% over the past decade. This development has
driven far-reaching changes, not just in how much disposable income the
group’s radiologists have, but it has also changed the number of
radiologists that can be hired, how much equipment can be purchased, how
many people want to train to become radiologists as well as how many
research and development dollars the imaging industry will be investing
in improving existing technologies and creating novel imaging platforms.

Volume to value

A related shock to declining payment is a fundamental change in how we are paid. For years both government officials4 and academics5
have blamed fee for service for many of the ills that are said to
afflict the US health care system and have called for alternative
payment systems. Some of those proposed have included value components
to replace volume based payments that include carrots (Accountable care
organizations (ACO), quality bonuses) and/or sticks (bundled payments,
quality penalties). Recently, the Centers for Medicare and Medicaid
Services (CMS), declared that it wanted to transition 90% of traditional
Medicare payments to value based metrics by 2018.
6

While fee for service is relatively clear, the role of radiologists
in value based systems remains ambiguous. The ACR has developed Imaging
3.0 to provide suggestions, guidelines and examples for radiologists who
are facing this challenge. In my consulting practice, this issue has
become the number one topic in 2015. Much of the difficulty revolves
around matters such as what percentage of shared savings in an ACO
should go to the radiologists, how can radiologists control costs when
they can’t control the ordering habits of referring physicians and how
much of an “outcome” is attributable to diagnostic radiology?

Measuring Value

Traditionally, health outcomes have been measured with statistics
such as life expectancy or infant mortality. Classically, this has been
the basis of comparing nations (and often disparaging the US with its
high costs). Using outcomes to do this only meets this standard if there
are no significant differences in inputs to the health care
system. For a more detailed analysis of the actual performance of a
health care system, you need to be able to account for variation in the
inputs that weigh on outcomes. At a minimum, the analysis should address
the most critical pre-existing inputs such as obesity, smoking history,
illicit drug use, and unsafe personal habits.

For many of us in radiology, even a reasonable analysis might be a
dismal failure since many metrics are not “smart enough” to measure the
quality of the health care system. Such analyses are strongly influenced
by many other factors including patient behavior and lifestyles, as
well as genetics, levels of violence, social structures, local
pollution, etc. If you are going to switch radiology to a value-based
purchasing scheme or tie payments to outcomes then you will not only
need to address the preexisting external factors, you will also need
more intelligent measures of radiology’s contribution within the whole
of the health care institution. These will need to be tied to actionable
elements of the imaging process, otherwise you are moving away from
volume based payment, but instead of going towards a true value measure
you are ending up with a clumsy or near imaginary measure of radiology’s
contribution to health care.

Decline in the independent practice of radiology

Outside of academic practice and employment with the government, the
traditional private practice of radiology in the US has been based upon
independent groups of radiologists working under contract in a hospital
setting and often concurrently for themselves in their group’s
outpatient facilities. This model has been eroded by several synchronous
waves of change including the development of national radiology
companies that provide comprehensive radiology services including
daytime coverage, the shift in many localities from groups in
independent practice to accepting hospital employment, as well as many
younger radiologists going directly into employed positions. It would be
smarter to be concerned about the decline in the influence of
radiologists and the loss of choices in the variety of models of working
as a radiologist. This latter factor has impact upon the ability to
contract, to capture value, on service and quality as well as on
professionalism. Moreover, the story of corporate dominance of radiology
in comparable nations such as Australia more than suggests that there
will be serious downsides to this trend.7 As we say in many
settings, diversity is good. Weakening or loss of the private sector
with a reduction in the types of radiology practice available should
concern all radiologists, not just those who are currently working in
the private practice model.

Fragmentation in the house of radiology

One of the peculiar characteristics of US radiology is the number of
organizations that claim to represent its interests. While exact data is
difficult to obtain, a ballpark number is that there are about 30,000
US radiologist FTEs engaged in the practice of the specialty in the US,
not including retirees or those in training. The report of the most
recent Intersociety Committee, an invitation only meeting that brings
radiology organizations together, stated that there are “50 plus”
radiology societies in the US.8 Even in “robust” periods for
the specialty it meant that radiology’s voice and influence were
fragmented. During difficult periods, such as the one that we are living
through now, there are and likely to be more ongoing challenges facing
US radiology. Fragmented leadership does not bode well for our ability
to cope effectively with these issues.

Funds available to support radiology conferences and organizations as
well as financial support and time to attend meetings are currently
declining. Given such limited backing the current number of distinct
radiology-focused organizations may not be sustainable. Now more than
ever we need effective, well-funded organizations that can advocate for
our views with powerful interests such as the government, major payers,
hospital chains, corporate entities and patient advocacy groups.

Declining interest in US radiology by US medical school graduates

An impending shock that directly impacts the future of radiology is
the decline in interest in radiology among US medical school graduates.
While the level of interest has oscillated more than once over the past
decades, it is currently in decline. The data from the 2013 match showed
that there were only 845 applicants for 1,143 slots. That was the worst
year since 1998.9 The current year also saw a substantial
shortfall in the number of applicants. Without enough highly motivated
and capable applicants, training programs will suffer initially and
ultimately the specialty itself will start to decline. The future of
radiology is our young radiologists and it will be shocking to be in a
specialty in decline.

One of the core tenets of many health care reformers in recent years
has been that the U.S. has too many specialists and that the imbalance
has been at the expense of primary case medicine and, furthermore, that
it contributes to the low perceived performance of the U.S. on
value-based metrics. As an incumbent specialty with many sub-specialty
disciplines requiring a high degree of cognitive training we are
particularly vulnerable to efforts directly aimed at the devaluation of
specialty care. The Affordable Care Act (a.k.a. Obamacare) included some
direct reductions in specialty reimbursement to pay for modest
increases in primary care that were instituted early on.

In addition, there has been some very prominent negative press as
well as focused public relations campaigns against physician specialists
and how they get paid through government sanctioned mechanisms such as
the Relative Value Scale Update Committee.
10,11 The trend towards diminishing the value of physicians is
also occurring on the other side of the spectrum with debates about
reducing the length of medical school,
12,13 reducing medical training or even, in some cases, eliminating the need for medical training before going into practice! 14

Conclusions

Certainly for most practicing US radiologists in 2015 there is a
significantly increased level of “future shock.” We have experienced a
great deal of change in recent years and there is little reason to
believe that these alterations are by any means over. By recognizing the
individual components of this “shock” we can perhaps take a more
focused approach to coping with the contributing elements, mitigating
them, or actually reversing them. The better we understand the root
causes of these current and pending changes,15 the more we can do to control our professional destiny.

Who decides what a doctor is worth? Washington Post Website.
http://www.washingtonpost.com/posttv/video/thefold/whodecides-what-a-doctor-is-worth/2013/07/19/7b5efb22-f0bf-11e2-a1f9-ea873b7e0424_video.html.
Accessed July 22, 2013.

Why medical specialists should want to end the reign of the RUC.
Replace the RUC Website.
http://www.replacetheruc.org/2011/08/16/why-medical-specialists-should-want-to-end-the-reign-of-the-ruc/.
Accessed July 22, 2013.

About the Author

Dr. Lexa is an academic neuroradiologist in Philadelphia and the
Chairman of the Radiology Leadership Institute of the American College
of Radiology. He is also Project Faculty, Spain and East Asia Regional
Manager, the Global Consulting Practicum, and an Adjunct Professor of
Marketing at The Wharton School of Business, University of Pennsylvania,
Philadelphia, PA. Portions of this material have been presented at
numerous U.S .and international meetings.